Electronic Communication

Request and Consent for Electronic Communication
First Name:
Middle Initial:
Last Name:
Other Names Used:
Birthdate:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Alt Phone:
I authorize OU to communicate with me via:
-or-

It is my responsibility to notify OU at the above telephone or address if my contact information changes.

I understand that I should not use electronic communication such as email or text message to contact my provider in the case of a need for emergency care.

I understand that refusal to sign this form will not affect my ability to obtain treatment from the above named OU entity.

I authorize the OU entity named above or its agent to contact me using the information I have provided on this form. I understand communications may concern all matters associated with my treatment and payment for my treatment, such as appointment reminders, insurance and billing information, and collection of any unpaid balances. I understand the security of email and text messages cannot be guaranteed and that unauthorized individuals may be able to access the messages.

I understand that I may revoke my consent at any time by providing the OU entity named above with a verification of my identity and completing the Request for Alternative Communication form. Revocation will not apply to communications that have been sent prior to the revocation date.

The information authorized for release may include substance use disorder records. This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2.

I understand the information sent via electronic communication may include information that may indicate the presence of a communicable disease or non-communicable disease.

I understand that this service of electronic communication is offered solely at the discretion of the OU entity named above and may be withdrawn at any time.

I understand this is not a request for release of my medical records.

I understand and agree to the statements above and wish to have electronic communication sent to me by the OU entity named above.

Signature of Patient, Parent, or Autorized Legal Representative*
Relationship to Patient:
Date:
*May be requested to show proof of representative status.

Minor Patient Consent For Treatment

Permission for informed consent for dental treatment for a minor patient.
I authorize , , aged 18 or over, to bring my minor child, , to appointments, make appointments, and consent to dental treatment and related dental services deemed necessary for my minor child. I understand that I must execute an Authorization to Release Protected Health Information/Treatment Records in order for OUCOD to discuss or disclose my child's medical information with the adult named above as part of the consent and treatment process.
This consent is effective from until I revoke it in writing.
Signature of Parent/Legal Guardian:
Date:

Acknowledgement of Receipt of Notice of Privacy Practices

Please click here to read the Notice of Privacy Practices: Notice of Privacy Practices
I acknowledge that I have been provided the University of Oklahoma's (OU) Notice of Privacy Practices(Notice):
  • The Notice tells me how OU will use my health information for the purposes of my treatment, payment for my treatment, and health care options.
  • The Notice explains in more detail how OU may use and share my health information for purposes other than treatment, payment, and health care options.
  • OU will also use and share my health information as required/permitted by law.
  • If I am an OU student receiving student health services, I consent to OU using and disclosing my treatment and education records it maintains for the purposes detailed in the OU's Notice of Privacy Practices.
Patient's Complete Legal Name
Patient's First Name:
MI:
Last Name:
Patient's Birthdate:
Today's Date:
Patient or Legal Representative* Signature:
*May be requested to show proof of representative status

Responsible Party Information

Responsible Party Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone:
Responsible Party Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Email:
Home Phone:
Cell Phone:
Employer:
Work Phone:

Authorization To Release PHI

Authorization to release health information/treatment records.
First Name:
Middle Initial:
Last Name:
Other Names Used:
PatientBirthdate
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Alt Phone:
If currently enrolled OU student, enrollment dates: to
I request that the health information (or, if I am a student, my treatment/education record) checked below from: to maintained or created by the Provider named below be released to the Recipient named below.
Initial here if infomation from your records may also be disclosed verbally to the recipient below:
Purpose of Request:
This authorization to release Protected Health Information verbally applies to discussions about information from my:
(Excludes Billing Records/Notes and Psychotherapy Notes)
(Excludes Psychotherapy Notes)
(If checking this box, no other boxes may be checked. A separate copy of this form must be complete to obtain any other types of records.)
OR only these portions of my record:
*The information authorized for release may include information related to mental health. Release of mental health records or psychotherapy notes may require consent of the treating provider or a court order.
Release Records From Provider/Clinic:

Name: OU Graduate Orthodontics
Address: 1201 N Stonewall Ave Rm 442     Oklahoma City, OK, 73117
Phone: 405-271-4148
Fax: 405-271-6012

Provide Records To Recipient:
Recipient Name:
Address:
City:
State:
Zip:
Fax:
Phone:

I understand:

  • I may revoke this Authorization at any time by providing my written revocation to the clinic named in the upper left-hand corner or the University Privacy Official at University of Oklahoma Health Sciences Center, P.O.Box 26901, Oklahoma City, OK 73129. My revocation will not apply to information already retained, used, or disclosed under this Authorization. Unless sooner revoked, the automatic expiration date of this Authorization will be months from the date of signature (12 months, if none entered.)
  • Unless the purpose of this Authorization is to determine payment of a claim or benefits, OU may not condition the provision of treatment or payment for my care on my signing this Authorization.
  • Information used or disclosed under this Authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy law. Student treatment/education records may retain continuing privacy protections in accordance with 34 CFR Part 99 (FERPA).
  • The information authorized for release may include substance use disorder records. This category of medical information/records is protected by Federal confidentiality rules (42 CFR Part 2). A general authorization for the release of medical or other information is not sufficient for this purpose. As a result, by signing below, I specifically authorize any such records included in my health information to be released. The Federal rules restrict any use of this information to criminally investigate or prosecute any alcohol or drug abuse patient. The Federal rules prohibit anyone receiving this information or record from making further release unless further release is expressly permitted by the written authorization of the person to whom it pertains or is otherwise permitted by 42 CFR Part 2.
  • I agree that costs for records will not exceed the floowing amounts, payable to the University of Oklahome prior to release of the records.
    • Paper Format - 50 cents per page, plus postage and mailer costs.
    • Digial Format - 30 cents per page, plus the cost of digital media (disk, flash drive, etc), plus postage and mailer costs.
    • X-ray/Film - $5 per x-ray/film, plus cost of media, plus postage and mailer costs.
  • There is a $10 fee for certification, affidavit, or similar documentation.
I understand and agree to the statements above and wish to have my records sent to the Recipient via email at
Signature of Patient, Parent, or Authorized Legal Representative**
Relationship To Patient
Date
**May be requested to show proof of representative status